Developing a module on the care of LGBTQIA+ individuals for health professionals: Research protocol.

Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual (LGBTQIA+) people struggle to identify a healthcare service that understands their problems and needs. Additionally, healthcare professionals also find it difficult to care for LGBTQIA+ as very little is studied or heard about management. The article presents a protocol for a pilot study aimed at the development of an LGBTQIA+ care curriculum for health science professionals. The study includes Phase I: The development of a curriculum based on a literature review and focus group discussion among LGBTQIA+ individuals, and Phase II: Pilot testing of LGBTQIA+ care curriculum. The study outcome will reflect the improvement in the knowledge of healthcare professionals on LGBTQIA+ care.


Background
The Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, and Asexual (LGBTQIA+) are a varied group of people with different gender identities, sexual orientations, and reproductive development.All members of the LGBTQIA+ community have different healthcare-related problems and requirements, even though they are sometimes grouped as a coalition.However, they share the stigma and discrimination that have hindered them from accessing quality healthcare in several ways (Agarwal & Thiyam, 2022;MacKenzie et al., 2020).Human health and social systems are interrelated.According to a Yang (2021) study, LGBTQIA+ individuals confront social challenges such as stigma, homophobia, discrimination, coming out, insufficient social support systems, and a lack of LGBTQIA+-friendly medical resources that not only put them in danger of physical and mental harm but also put their health at risk.LGBTQIA+ individuals face discrimination, violence, and bullying as they come to terms with their identity.LGBTQIA+ individuals are more vulnerable to mental health problems including anxiety and depression as a result of this type of minority stress (Yang, 2021).According to the original model of Meyers (2003), stressors are generated from having a minority status, which is overrun by the circumstances of their environment, leading to mental and physical ill-effects that have a negative impact on the lives of the socially stigmatized LGBTQIA community.Individuals can self-identify in different ways, including gender identity and sexual orientation.For the remainder of the text, we will refer to this spectrum collectively as the LGBTQIA+ community.The terms "L" for lesbian and "G" for gay refer to people who are attracted to people of the same gender; "B" for bisexual means they are attracted to people of both genders; and "T" for transgender means they identify as a gender other than the one they were given at birth; Q for Queer a sexual orientation that isn't only straight or heterosexual.It's a general word that covers those with gender-fluid or non-binary identities.It may also imply 'Questioning'-A person who seeks answers about their gender identity or sexual orientation is said to be "questioning"; "I" stands for intersex, a term used to characterize individuals who do not conform to traditional classifications of female or male due to differences in their reproductive anatomy or sex features.Differences may exist in terms of internal sex organs, hormones, chromosomes, genitalia, and/or secondary sex traits; "A" stands for "asexual," a term used to characterize someone who is not attracted to or desirous of other people sexually.It's not the same as celibacy when individuals choose not to engage in sexual behaviours.The '+' recognizes and includes additional identities and orientations not covered by the initials and refers to the community's dynamic nature (Agarwal & Thiyam, 2022).A person's sexual and emotional attraction to another person, any resulting behaviour, and/or social connection are all considered to be part of their sexual orientation.The strongly held, innate notion that a person has of being a boy, a man, or another member of the male, female, or alternate gender is considered their gender identity.The way society views homosexuality varies widely between countries and historical eras.Heterosexuality is now accepted as the standard across the globe.LGBTQIA+ individuals face stigma and stereotypes in many countries.Despite the Delhi High Court's 2009 decriminalization of homosexuality, on December 11, 2013, the Indian Supreme Court upheld section 377 of the Indian Penal Code, which criminalizes adult consensual same-sex intercourse (Kar et al., 2018;Sathyanarayana Rao & Jacob, 2012;Somasundaram & Murthy, 2016).The Supreme Court of India recognized LGBTQIA+ people as the third gender in April 2014, and any discrimination against them was viewed as a violation of their constitutional rights (Kar et al., 2018;Khatri Babbar, 2016).
Despite recent developments in the acceptance of LGBTQIA+ individuals, education on LGBTQIA+ health requirements for health professionals still lags far behind despite evidence showing a tremendous rise in LGBTQIA+ acceptance and the achievement of equality in many sectors.Multiple studies and reviews of health issues have shown a persistent gap in healthcare education, with no standard texts that include information concerning care for LGBTQIA+ individuals (Keuroghlian et al., 2017).LGBTQIA+ community members encounter several difficulties regarding sexual orientation and gender identity in a heteronormative culture.Additionally, they frequently experience prejudice and sexual assault.

REVISED Amendments from Version 1
A few changes are made in version two of this manuscript.The title of the manuscript is changed to "Developing a module on the care of LGBTQIA+ individuals for health professionals: Research protocol" as per the suggestions received from the reviewers.Version 1 contains the term 'curriculum,' which has a broader usage, and based on the suggestion from the reviewers, it has been revised to 'module.' for better understanding.The previous version of the title contained 'Implementation' and 'testing,' which are the module's development steps; hence, only development is highlighted in the new title.A few minor changes are made in the figures, tables, and text to accommodate suggestions given by the reviewers (E.g.'Curriculum' is changed to 'Module').The introduction section has been improved with additional details.A uniform use of the term 'healthcare professionals' was adopted throughout the text in version 2 instead of medical professionals, medical students, doctors, etc.The manuscript's abstract is also revised based on the changes made in the main text.A few additional studies were reviewed, and references are cited in the manuscript.
Any further responses from the reviewers can be found at the end of the article Further, their medical requirements are more likely to be overlooked or socially rejected due to their sexual orientation and gender identity, which can affect their medical rights and the medical care they receive.LGBTQIA+ individuals frequently struggle with coming out when dealing with medical professionals.Two things worry them; First, medical professionals' ignorance, bias, and discrimination may impair their right to get medical care.Second, incomplete information disclosure may influence a disease's diagnosis or possibly lead to a misdiagnosis.LGBTQIA+ individuals must carefully balance the risks of coming out with the benefit of having the right medical attention and support.These factors frequently lead to psychological pressure, which is harmful to both physical and mental health (Yang, 2021).
The stigmatized and discriminated populations must be addressed by healthcare practitioners.Understanding how medical students feel about homosexuality is crucial for improving the healthcare system.Patients who identify as LGBTQIA+ have encountered stigmatization, discrimination, and even refusal of care within the healthcare system (Kar et al., 2018).In 2017, the Joint United Nations Programme on HIV/AIDS UNAIDS report stated that LGBTQIA+ individuals made up 4.3% of the population in India who were at high risk of contracting AIDS (Kar et al., 2018).Due to the underrepresentation of such information in medical school curricula, clinicians may not be aware of or sensitive to the needs and issues faced by LGBTQIA+ patients when they encounter them (Sequeira et al., 2012;Magnus & Lundin, 2016).
Healthcare professionals are frequently not trained in or sensitive to the requirements of LGBTQIA+ individuals' health.Additionally, it might be challenging for professionals to talk about identity in general, especially when it comes to sexual orientation and gender identity.Medical education institutions can sometimes become the breeding ground for a heteronormative ideology that supports heterosexualism (Lundin, 2011;Magnus & Lundin, 2016).Heteronormativity refers to the belief that only two opposite and mutually complementary genders existor that gender and sexual variation simply do not exist in social institutions (Kannisto, 2019).Healthcare professionals frequently lack the necessary training and awareness regarding the health needs of LGBTQIA+ individuals.Moreover, they often find it challenging to have a conversation regarding sexuality, especially when it comes to gender identity and sexual orientation.LGBTQIA+ individuals have obstacles in receiving adequate healthcare because of inadequate training, heterosexist attitudes, or both.Inaccurate risk estimates for pregnancy, STIs, and the ineffective or improper use of screening tools can all be caused by heterosexist attitudes.These challenges could have a detrimental impact on the management of these patients' treatments and, eventually, their health (Wahlen et al., 2020).
The LGBTQIA+ community is substantially more likely to experience various risk factors for poor health than heterosexual people, such as being less likely to have health insurance, being more likely to be obese, smoking more regularly, and engaging in binge and heavy drinking, the population's age warrants additional attention.In addition, compared to heterosexual women, lesbian and bisexual women may undergo fewer preventative screenings for colon, breast, and cervical cancer.This is partly due to fear of not receiving respectful healthcare.Healthcare professionals are at the forefront of this effort and have the chance to treat everyone with respect, regardless of their sexual orientation and gender identity.Lack of time, finances, education, and clinical experience are a few obstacles that can prohibit physicians from providing respectful medical care (Walker et al., 2016).Doctor-patient interaction is essential for enhancing people's health (Parker & Bhugra, 2000).Patients may opt to keep their sexual orientation and gender identity private.In such situations, healthcare professionals must be vigilant and compassionate to deliver the best care (Grabovac et al., 2014).
There are no such policies or curricula for treating LGBTQIA+ patients in India's healthcare sector.LGBTQIA+ people have common social tendencies and decisions that impact their behavior while seeking healthcare, preventative health measures, and illness risk (Kaufman et al., 2014).It is vital to make accessible, responsive, appropriate, and wellresourced healthcare services provided by knowledgeable and trained healthcare professionals to support a better patient experience.Higher education institutions and healthcare organizations have a significant role in developing curricula (Cui, 2023) that can be accessed by all groups, including those who identify as LGBTQIA+ (McCann & Brown, 2018).Healthcare institutions must create a welcoming environment and make allowances for people with diverse gender identities and sexual orientations (Hafford-Letchfield et al., 2017).
Medical school teachers play a vital role in helping medical students become better prepared to treat these underserved communities and reduce healthcare disparities (Alhanachi et al., 2021;Chinchilla & Arcaya, 2017).Training healthcare professionals during their studies can help them feel more at ease when caring for these patients and give better treatment, an essential technique for improving understanding and attitudes about LGBTQIA+ persons among healthcare professionals (Wahlen et al., 2020).Inculcating positive LGBTQIA+ attitudes among healthcare providers plays a great role in reducing homophobia and transphobia (Gegenfurtner, 2021).The scope of the proposed research is to develop a module on the care of LGBTQIA+ individuals for health professionals and pilot test on faculty and students of health sciences, including faculties and students from MSc nursing, MPhil psychology, Head nurses, Medicine, and Nurse educators in the form of workshops.For this purpose, a need assessment through a review of the literature and focus group discussion with LGBTQIA+ individuals will be done.The project contributes to enhancing the UN's sustainable goals, such as SDG 3-Good health and well-being, and SDG 10-Reduced inequality.

Research questions
How is a module on the care of LGBTQIA+ individuals on health professionals effective in increasing their knowledge?

Primary research question
What are the healthcare needs of LGBTQIA+ people?
To answer the primary research question, lead questions will be used to assess LGBTQIA+ individuals' care needs, barriers to accessing care, and expectations from healthcare professionals.

Secondary research question
How effective is a module on the care of LGBTQIA+ individuals in increasing the knowledge of health professionals?
To achieve this question, a structured knowledge-based questionnaire on LGBTQIA+ care will be administered to the health science students and faculty to assess their knowledge about LGBTQIA+ care.

Hypothesis/Assumptions
It is hypothesized that a module on the care of LGBTQIA+ individuals will significantly increase the knowledge of health professionals.
Based on the previously published literature related to the needs of LGBTQIA+, it is assumed that a.
LGBTQIA+ individuals experience stigma and discrimination.
b.The present health science curriculum does not have a specific unit that deals with the management of LGBTQIA+ health problems.
c.There is a lack of structured guidelines for managing the health conditions of LGBTQIA+ people.

Design
The study includes two phases: Phase I -development of a module on the care of LGBTQIA+ individuals for health professionals based on the literature and the need assessment through the focus group discussion among LGBTQIA+ individuals; and Phase II -A pilot testing of the module for health science faculty and students with pre-and post-test assessment design.A conceptual framework of the research design is shown in Figure 1.
Phase I: Developing the module a. Literature review A module on the care of LGBTQIA+ individuals for health professionals will be developed based on the detailed literature review and analysis of focus group discussion (FGD).The literature will be reviewed in detail through different sources to understand the needs of the LGBTQIA+ community.This includes academic research databases such as SCOPUS, Web of Science, PubMed, Science Direct, and CINAHL Complete.The grey literature search will also be initiated.The literature search is primarily conducted to find out the existing healthcare needs of the LGBTQIA+ community, and it does not involve systematic reviews.The literature on the needs, problems, and expectations of LGBTQIA+ will be studied and used to develop module.

b. Focus group discussion
The FGD will be conducted in a district government office in coordination with the local government health department.
The Principal Investigator will moderate the FGD by following the standard methodology (Kitzinger, 1995).The data will be collected from the participants after obtaining administrative permission from the authorities.The participant information will be explained in the local language, and a signed informed consent form will be obtained from the participants to collect the data and for audio recording.The participants' sociodemographic data will be taken, and the participants will self-report their sexual orientation and gender identity.The lead questions prepared for the FGD will be used to conduct the discussion (Box 1).After receiving consent from the participants, a discussion will be initiated using the lead questions.Participants are encouraged to communicate and discuss their healthcare needs and expectations from the healthcare facility.Based on the participant's response, probe questions will be asked till all the questions are answered.The FGD will be recorded using an audio recorder with the consent of the participants and nonverbal communication during the discussion.It will be used as an adjunct while transcribing the discussion.A sociogram also i. Explain any other information you would like to bring to our attention.will be drawn to record the interactions among the participants.The FGD session will be closed by the moderator after the important points have been summarized to the participants.The team will thank the participants and compensate them for the quality time spent by the participants.The data gathered will be thematically analyzed (Braun & Clarke, 2021;Kyngäs et al., 2019), and will be used to develop the module for health professionals.

c. Development of a module on the care of LGBTQIA+ individuals
Based on the literature review and FGD analysis, the authors will draft the module on the care of LGBTQIA+ individuals for health professionals.The content of the module is divided among the authors to have six chapters.Following the development of the module based on the literature review and the outcomes of the focus group discussions, the draft will be referred to the experts for content validation.Two experts will conduct this validation: one will be a transgender person with expertise in medical science, and the other will be an expert in health sciences education.The final module will be developed based on the expert's suggestions.The developed module on the care of LGBTQIA+ individuals for health professionals will be used for Phase II.
Phase II: Pilot testing of the module The module will be pilot-tested in the form of workshops for faculty and students of health sciences in the workplace.The faculty and students will be from nursing, medicine, psychology, and nurse educators.The workshop will be for one day.Knowledge will be assessed before and after the workshop using a questionnaire.The tentative topics covered in the workshop are an introduction to LGBTQIA+ care, inclusive communication, LGBTQIA+ community and health caretreatment management, mental health services for LGBTQIA+, research and evidence-based practice, interpersonal communication, and ethical and legal issues in LGBTQIA+ health care.Feedback from the participants will also be taken for the modification of the module.The module will be finalized after the pilot study, and recommendations will be submitted to health sciences institutions, their regulatory bodies, and funding agencies.

Phase I
Phase I includes an FGD to assess the healthcare needs among self-identified LGBTQIA+ individuals.The result of the FGD and the literature review will help in preparing the module.
One face-to-face FGD of 10-15 individuals who are a representative number of the self-reported LGBTQIA+ community will be recruited using purposive sampling.The details of the participants will be collected from the district authorities.
They will be contacted to schedule the FGD.The sample size is kept under 10-15 to support the depth of FGD and subsequent analysis.

Inclusion criteria
• The participants who self-report as LGBTQIA+ community and can speak in Kannada or English.
• Individuals who are above the age of 18 years.
• Individuals who are willing to participate in the focus group discussion.

Exclusion criteria
• Any individuals who are crossdressers.
• Any member of the LGBTQIA+ community who has a diagnosed mental disorder listed under chapter F of ICD 10, except gender identity disorder.

Drop-out criteria and withdrawal
Data collection from participants will cease when they withdraw their consent to participate, and the data that is in question will be excluded during the analysis.

Phase II
The participants for phase II will be selected from the health sciences institutions offering medical, nursing, and other health science programs through their heads of the institution.Faculty and students will be recruited face-to-face for the study, and the module will be pilot-tested both among the faculty and students through workshops.No dropouts are expected as the workshop is for one day.
The number of participants for this group will be based on the formula: where; α (two-tailed) = % Threshold probability for rejecting the null hypothesis.Type I error rate.The N thus calculated is rounded up to 30 participants from students and faculty groups.
Students from medical (n = 10), nursing (n = 10), clinical psychology (n = 5), and senior nurses from the teaching hospital (n = 5) will be trained in the 'student workshop' whereas faculty from medicine (n = 10), nursing (n = 10) and psychology (n = 5) and middle-level nurse managers or educators (n = 5) will be trained in the 'faculty workshop'.Undergraduate students and faculty are excluded from the 'student workshop', and similarly, students are excluded from the 'faculty workshop'.

Outcome measures
The outcome variables will be: Phase I: • Needs of the LGBTQIA+ individuals (analyzed) from FGD • A module on the care of LGBTQIA+ individuals for health professionals Phase II: • Knowledge of health professionals on the care of LGBTQIA+ individuals is measured using a structured knowledge questionnaire.

Primary outcome
The healthcare needs of LGBTQIA+ individuals will be assessed, and the data gathered will be used to develop the module for health professionals.

Secondary outcome
The module developed using the data gathered by FGD, literature review, and experts' inputs will positively influence how LGBTQIA+ individuals are getting cared for by healthcare providers.

Plan for data analysis
Phase I The FGD will be analysed by thematic analysis (Braun & Clarke, 2021;Renjith et al., 2021).The focus of the FGD analysis is not to identify the individual contributions to the discussion but to present the spectrum of opinions of the entire group (Van Eeuwijk & Angehrn, 2017).The data will be divided into simpler text units for coding, and the coding will be done manually.Units of meaningful text corresponding to similar codes will be grouped and categorized systematically by the authors.Any differences in the process of coding and categorizing will be resolved by discussion among the authors.Consensus will be achieved during these face-to-face discussions.The codes will be categorized into inductive and deductive.Inductive codes will be content-driven and raised by participants, whereas deductive codes will originate from the discussion guide and will then be verified with data (Hennink et al., 2019).
Phase II: Descriptive statistics like frequency and percentage will be used for the data analysis of the workshop participants.The knowledge data will be analysed using a paired t-test.

Dissemination
Results will be disseminated via presentations at appropriate scientific conferences and meetings of professional bodies.
The study will also be published in peer-reviewed journals, professional and institutional repositories, etc.The results will be discussed with governmental bodies and other stakeholders for broader implementation.

Status of the study
The study team completed the draft module and is currently in the process of pilot-testing the module on the care of LGBTQIA+ individuals for health professionals (phase II).The study is expected to be completed by December 2024, and the results will be published by 2024 and 2025.This protocol will help in reducing unnecessary duplication of effort and the costs of future studies.

Discussion
The previous study findings show that LGBTQIA+ individuals face more difficulties accessing care because of their sexual orientation and gender identities.The study found that young adult lesbians had a harder time getting access to care than young adult homosexual males.This finding is consistent with earlier research that identified differences in the healthcare experiences of sexual minority individuals.Additionally, due to negative experiences associated with their sexual orientation and identity, gay males were more prone than lesbians to delay care.Young men may be more forthcoming about their sexual orientation and identity in healthcare, which may increase the potential for negative experiences, whereas young women may be more reticent to disclose their sexual orientation and identity to providers and, as a result, feel limited in their ability to access affirming care (Macapagal et al., 2016).
Contrary to earlier findings, few individuals claimed to have encountered LGBTQIA+-related discrimination in medical settings.Furthermore, the majority stated that telling their provider about their gender identity and sexual orientation had a neutral to positive impact on their care (Mosack et al., 2013).The findings from previous studies suggested that changes in the healthcare system will promote inclusive care.Studies have shown that reluctance to talk about sexual orientation and gender identity was brought on by ignorance of the medical requirements for LGBTQIA+ patients (LaVaccare et al., 2018).According to a previous research study, students who had more contact with LGBTQIA+ patients were more likely to ask about a patient's sexual orientation and gender identity and check for children in the patient's family.The disclosure of this information during patient interactions may be improved by early intervention by educators who teach students appropriate questions to ask during the history-taking process (Sanchez et al., 2006).
The current study will explore the healthcare needs of LGBTQIA+ individuals and will result in education programs and initiatives that can improve knowledge about LGBTQIA+ individuals.It will also provide practical techniques that can easily be included in the health science curriculum, which will help reduce disparities.The module will improve the healthcare professionals' knowledge about sexual orientation, gender identity, sexual behaviour, and sex anatomy comfort of LGBTQIA+ patients.It will enhance the self-confidence and comfort of healthcare professionals who treat LGBTQIA+ people.Previous studies have found health professionals who are trained in inclusive LGBTQIA+ care were able to address sexual health without shame, hesitation, or ignorance and help the members of the LGBTQIA+ community (Agarwal & Thiyam, 2022).The module will summarize the healthcare needs, barriers, and expectations based on FGD and primary care recommendations for LGBTQIA+ patients.This study will support the necessity for a curricular framework to reduce unconscious bias among students of healthcare professions toward LGBTQIA+ patients.

Conclusion
The study will address the critical gap in the healthcare professional curriculum in terms of LGBTQIA+ care.The module will enhance the skills and knowledge of healthcare providers in caring for LGBTQIA+ individuals and help them understand their needs and expectations.It will promote healthcare professionals' positive attitudes toward LGBTQIA+ patients and improve comfort working with LGBTQIA+ patients.The module will guide researchers and educators looking to reduce prejudice against LGBTQIA+ patients in healthcare professionals, as well as a framework for teaching students to recognize and overcome their own biases.Educational Strategies that reduce bias in healthcare providers are essential steps to improving LGBTQIA+ communities' access to treatment and reducing health inequalities.

Project Plan
Table 1 depicts the activities and publications that will be carried out throughout the project.The project will endure for two years.

Ethical aspects
The Institutional Ethics Committee of Kasturba Medical College and Kasturba Hospital reviewed and approved the proposal on 11 th May 2022 (IEC1-138/2022).The protocol has been registered to the Clinical Trial Registry-India.Permission has been obtained from the local government authorities concerned, and written informed consent has been taken from the participants in the study.The data relating to the participants will be kept confidential and used anonymously for this study only.Codes will be used for each participant.impact of the proposed research The module developed using the data given by the participants will positively influence how LGBTQIA+ individuals are being cared for by healthcare providers.This project makes a timely contribution to discussions concerning the function of professional educational interventions, which evaluates the impact of educational curricula and training for healthcare students and professionals on LGBTQIA+ healthcare issues.A policy document will be made at the end of the study by highlighting the study's implications and will be disseminated among the ministries and other regulatory bodies of health and education.
3: Background: April 2014: Reference to be provided.5.Page 3: Background: "Although the Delhi High court……………….",This sentence to be modified for clarity.6.Page 3: Background: Delhi High Court 2009: -reference needed.7.Page 4: para -1:-"Hetero sexist attitudes may result in Inaccurate Risk Assessment" This sentence to be justified and rewritten for clarity .8.Page 4; para 2: Health institutions should make room for individuals -Needs to be rephrased.9.Page 5 : Research Plan :-points b and c , b.The present health science curriculum does not have a specific curriculum that deals with the management of LGBTQIA+ health problems.
○ c.There is a lack of structured guidelines for managing the health conditions of LGBTQIA+ people.These points should be highlighted and discussed adequately as the need for the study.
○ 10.Introduction to be rewritten, as it is not aligned with the objectives of the study.2023 Ramoo V.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Feedback to authors
Dear authors, thank you for the opportunity to read and review this interesting research protocol.My suggestions/comments to further enhance the paper are:

Title:
The title effectively conveys the primary focus and purpose of the study.It clearly indicates that the research aims to develop, implement, and evaluate a curriculum for health science professionals regarding LGBTQIA+ care.It's specific and informative, which is essential for attracting the right audience and communicating the study's objectives.Overall, the title is wellconstructed and aligns with the research's objectives.

Scope of the Study:
The scope of the study appears to be appropriately defined within the title and is further elaborated upon in the abstract and introduction sections of the research protocol.It includes three key phases: curriculum development, implementation, and testing, with the overarching goal of addressing healthcare disparities and enhancing LGBTQIA+ healthcare education for health science professionals.
However, to further clarify the scope: In the introduction section, consider briefly mentioning the specific healthcare disciplines or professions within "health science professionals" that the curriculum is intended for (e.g., physicians, nurses, social workers) to provide a more precise context.I noted only the need for medical students and faculties is highlighted in the text.The importance for nurses and other healthcare professionals is not emphasized.Define who the healthcare providers are and use a consistent term either as healthcare providers or as healthcare professionals (healthcare science student mentioned in Figure 1).Avoid using them interchangeably, as this may confuse readers.Also, consider where students can be considered as providers or professionals.
It is noted also the authors had mentioned assessing knowledge of LGBTQIA+ health needs and sometimes knowledge of LGBTQIA+ care -please be consistent.

Research question
The research question requires minor refinement of the sentence structure, for example: How does an LGBTQIA+ curriculum impact healthcare providers' knowledge of LGBTQIA+ care?However, in the the authors plan to assess the "how" using a quantitative approach, I would suggest rephrasing to: "To what extent does an LGBTQIA+ curriculum quantitatively improve healthcare providers' knowledge of LGBTQIA+ care?" Suggestion for the secondary research question as this will be assessed using a pre-post approach: To assess the effectiveness of the curriculum in improving healthcare professionals' knowledge of LGBTQIA+ care.

Phase 1 -Development of curriculum
The curriculum development process should include a strong focus on cultural competence and sensitivity.This includes not only understanding healthcare needs but also addressing the unique cultural and ethical aspects of caring for LGBTQIA+ individuals.
I would suggest that in addition to FGD and literature review, the authors should consider incorporating insights and expertise from healthcare professionals experienced in LGBTQIA+ healthcare.Experts can provide valuable guidance on best practices and ensure that the curriculum aligns with clinical reality.
The content of the expert validation of the curriculum requires further elaboration in terms of the panel's expertise, the number of experts involved and the specific analysis process to be carried out.Future details on these aspects would be valuable to ensure transparency and accuracy in the validation process.I recommend determining: The composition of the expert panel, including the diversity of expertise among panel members (e.g., LGBTQIA+ healthcare, medical education, curriculum development).

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The total number of experts who will participate in the validation process.

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A clear description of the analysis process, indicating the criteria and guidelines against which the curriculum will be evaluated.
○ How experts will provide feedback and recommendations and whether there will be a formalized assessment or evaluation system for assessing curriculum components.
○ FGD participants: While the authors mention recruiting a representative number of self-identified LGBTQIA+ individuals, consider expanding efforts to ensure diversity within the sample.Mention whether they will actively seek participants from diverse backgrounds, age groups, and gender identities to capture a comprehensive range of perspectives and experiences.
The rationale for selecting a sample size of 10-15 participants is well-explained.The authors highlighted the importance of depth in the Focus Group Discussion (FGD) and subsequent analysis.It would be helpful to mention whether this sample size is consistent with previous research or guidelines in the field to further support the appropriateness of the sample size.
Exclusion criteria should not be the opposite of inclusion criteria, for example: "Any person who is not belonging to the LGBTQIA+ community" is not required.

II -Pilot study
Insufficient information has been provided regarding the measurement instrument, and the questionnaire on knowledge.It is essential to include comprehensive details regarding the development or adaptation of the instrument, its content, the validation process, and reliability testing.

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The time interval between the pre-and post-test and its rationale.

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Figure 1 needs a more detailed description of the process.Figure 2 -not clear of the activity in Workshop I.

Discussions
The discussion touches on key points related to previous research and the potential impact of the curriculum.However, further elaboration, interpretation, and explicit connections between the current study and previous research would enhance the overall clarity and depth of the discussion.It would be advantageous to explicitly state how the present study seeks to build on or contribute to existing knowledge in this area.This will help readers understand the unique contributions of your research.

All the best
Is the rationale for, and objectives of, the study clearly described?Yes

Is the study design appropriate for the research question? Yes
Are sufficient details of the methods provided to allow replication by others?Partly Are the datasets clearly presented in a useable and accessible format?

Not applicable
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Nursing education, Critical care nursing and Nursing Management and Leadership I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Figure 1 .
Figure 1.A conceptual framework of the research design.

the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests:
Research question is not aligned with the title of the topic and study objectives should be provided.What are 'The gaps' in the present curriculum / Gaps and lack of competency of medical professionals in communicating with and management of LGBTQIA+ subjects , whether it should be a part of the AETCOM modules of the present CBME (Competency Based Medical Education ) medical curriculum should be discussed in the background section.11.Primary Research Question and Research Objectives are not clear.12.In alignment with the research question, assessment of knowledge about LGBTQIA+ Care has to be included in the title.13.Based on the previously published literature related to the needs of LGBTQIA+, it is assumed that……….: has to be rephrased and modified.It is mentioned "To achieve this secondary research question, a structured knowledge-based questionnaire on LGBTQIA+ care will be administered to the health science students and faculty to assess their knowledge about LGBTQIA+ care."This structured questionnaire should be provided in the appendix/as annexure section.Whether Validity and Reliability of the was tested, CVI and CVR were calculated;, whether I-CVI (Item level CVI )/ S-CVI (Scale level CVI ) were also calculated ?Validation process should be elaborated.23.Page 7: Phase -11: Inclusion criteria for phase -2, age group of the health care students participating in the study to be given.24.Page 8: How the Assessment of primary and secondary outcomes would be done; to be described.No competing interests were disclosed.